HomeMy WebLinkAbout29895 / 78-12BL�E:�Ii�F?R 21, 197fi � ll F2ESOL'1TIG�.
�pasL: �cr_�m �u�.TZ�z^�rr n��s
Iidlri'iI�T"_J BY: Pr�R��'iONN�L, DEP1R'P�T
47ETM;?'r;AS, t�w C-�y o` Os;il<osh on tl:� 21st day of Mar.ch, 1974, �<,op*.c:d an
TT.il"f'JY?"� .=�_t'.E:�'_ii:�:� P�1�=� t:.A r?....-tlOi��g fjf �I'h,.E�' �711,:-�P dRC3 fl.fE G�c'i:.'�U?Y?rt'3, dP,�
��rri�t:.r=.a, t1�e Followi.ny fi;:e de;�.> �,�r_t ��rscn�?el has met the recnz�::�r�-,,,��
of saic. O:�iY�rr?n i;xt�r�io:t Folic,y an3 .,as rE�luesced a o:�e-�year e;,-tensi_o;:i oF his
em�loy:rent:
GERAL!] F. SCF�TJSh� - 3rcl F,eqt�st - Fire D partmint
Date of Firth: Fei��sary 25, 19?_2
Oria,in�l, 1?et-i.tien�nt Da=e was t^;+=cti 31., 1977
I1rUloyir��it Fti-ti�::,-c,n tt:r�ugh Niarch 31, 1980
NOW, Tf�":"?�'On", Px. Ii R;,:'OT,� by th:� C�m�n. CoLU�cil Of the City of Oshkos�+
that the for:�;;ouig extc:��:ion is hereby gr�ntx�l.
SJp7,iITi��i F; �
— 1z —
b".r. Kenneth Schiefelbein, Pre�.
Cshkoah Canmon Council Cct. ?_3, 1979
215 Church Ave..
oshkosn, wi. 54901
Dear Sir h Council b'�bers;
Once again I am requesting for an extension with the Oshkoeh
Fire Dept. as an equiptment operator for another year. I will
be 57 Years old on reb. 25, �979.
ESiclosed is my medical examination report from Ar. Wm. Weber.
If there afie any queations regarding my phyaical report
please caJ.l Dr. �eber or my�elf.
Yours truly,
� � — .
.�` `�"�` � �� � ._ ,.� ��s
. ' '�
1
�
�
THE MEDICAL EXAMtNAT10N REPORT
POLICE AND FIRE DEPARTMENT
J t : /,
Ezamination for L'E'F"'t
�
Datr �P�"3��''.—� �—
1. Name (pcint) �Zp c^\� �C ,� 1 P r� G k.P 2. Date of birt�+ a' a�.- � a 3. ASa,S f o.
4. Signacure of applinn ,L�.
„ ' � 7�
S. Heig6 S� �! 6. Weig6L 7• �� •
WitLwl f6oq StciDP� � Ordiaary clotha E�p ed obillq Nuuml
e. Er�st,t: sn�ua 'r��: i.ert xo/ 3SZ x;gt� zo�� so� zo��
Correctad to: Left 20%r7-�2. R86t 20/� � Both 20/��
Color ta� 110 f Ync�
9. Hearing: R ear C�{ L. eaz ��� Dischazge? `?`��� 10. Nose
O/G .
11. Dental sucvey: Mazk [eeth "O" if capped or pivoF, "I" if missing; "X" if carious; "F" if false.
R 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 L Perfer� Catia sligh•
8 7 6 5 4�3 2 1 1 2 3 4 5 6 7�8
12. Toas'� ���`��r 13.
14. 'I'6YroiiL L°1k 15.
16. Lmgs: Check for as[hma, tubemilosis, bronchiti+, c6ese R-ray fio
17. Heact: Cardio-vasc�ilar syste 6�; '
Pulse ratr �� Blood prasure: Sys[olic
1& Gastco-inte�tinal mct: C6eck appendix . ���
Check foe gsscric ulce�� .
Gall bladder ����r�'
��. c-r
19. Genito-utinary: vencreal d'uease
•yc,�.
Vazi[otele. —
Kida�ps_ �/�
Good iepair �� Caria marked
Pyouhea_ Need deanin� .
Wasserma
Hydcocel ���f� ���� �
20. Her '^
�-Z�tta�-c-"� 21. Varicose Vein /%"tiCJt�'% L� � - -
(vott torm) n!�
22. Hand E�L 23. Fe C
C/L (fla[ or aher coodirioa)
f'
24. Bonn and joinn_ ��� � 25. Spin
26. Disabilities: (duonic caracrh, sinus, fis�ula, iectal diseaxs, cucanaous di+eeses, e? ���`�`�'
27. Illneu and injai . �"�"""' ,, - . _ . _ �. �� .
�
28. OPerauo �• ,•- - - - - ' - - -- - -
29. Neurotie tevdenci '"'��' � . ��2�
L % C��,;�f��..�
30. Codd thi� msn perform duty involviag being on his Eeet for 12 hours continuousiy? �
31. Could t6iu maa perfo m duty involviag long houn of dury involving vcting or ridiag? ��
32. Remacica ���"�1
I HEREBY CEA'FIFY '1'HAT THIS IS A TRLtE RF.COBD OF THE MEDICAL EXAMINATION OP THH ABOVE EX��t�qINEE ,�
AND THAT I HAVE FOUND HIM �QUALIFIED ❑ gySICALLY FOR THE DUTIES OF� �rJi�Ls�lv�rC�'����"�-�
QUALIPIED � �' (�
. -- ��l� r._.�._y. .-�C�-� ....1�trD.
Medinl Fz�mixe
MEDICAL HISTORY STATEMENT
(To be taken in presence of examining physician.)
Do you believe you sse sonnd and we11 now?�P� �e you subject to dizziness?�\(7 To seven 6eadacLeT n n
To pain in the breau?�^To Huttering of s�e 6eard l�C� To ehortnas of breath? a To cougM? h n
To diarrhea? aCl To piln> nLZ To rheuma�asm? n� Have you had sore eya or any defat of vision?�cZ._
Runoing From either ear? n Ti . Is ywr senx of hearing good?�_ Have you 6ad 50 or conwlsiom? r�_
If so, how frequendy? Uncouscious spols? � L� IF so, bow frequendy?
Asthma? hQ. APpendidus? h� if sq were you operaced upou?_ Gonorrhn7�Z, _
�m� A sote of any kind upon your penis? �(i Wheo?
Any swdling about or of your cesticles?___.i� D A boil near che anus? (fistuta)? 'n i1
Have you been rupmredt -Y\D Do yoa drink intoxicaciug Iiquon to rxca�? n�_
If not, �o what extend � r n-S�.�n � Do you use or have you used opium, morQ6inq cocainq ur anp
other narcotics? 1�n When? Wha[ was the cause of your fachels death? ��_ L (t`�'?c�Ck
Whet was the caux of yout motheCs death?—C'_13.LL\C (� �Has any membet of your familq 6ad cuberculosia,
inssnity, epilepsy, or in8ammatory rheumatismt '(1(�1 ��
Have you ever spit biood? �"�7� Have you ever bcen hur[ upon the head? Yi�
Answer
Hsve you 6ad a spnin? �� A s�i$ joint? � t"� A boae or joinc ou[ of place? n� A bone broken? l�T_
C�hat bones broken?�1��,`lC � W6en? �q3�� Caux?�f'-N� ���u..� C)� `�
�-- n°�-�'+- �� �'?�.��y Are yoa subject [o
paintul com� or sore feet? 11 �� �ltention carefuliy iajuries or surgical opeca[ions you may
have had upou any part of your body, especially burns, cucs, severe bruisa, or war wound� ��11I°Q.
What Lospitalizatinn have you had for U. S. wa[
Give aame md addreb of p6ysician who last attended yoq Eor whac ailment, w6en? �'�'� Cr �1.�P�j,P,r
.�t� �Q i l �-_, __ f�L C-r�n�-C�.V
—1-
I hereby certify tha[ the foregoing sta[emencs are true to the bes� of my koowledge and belief.
Sigaa�e of Applicant
�:%r�1 ��6-�tc
� (sigu fall name)
�
�
C �"
� j
N ;�. q I
3 a H �j
�Z s � w {
p W � Q � H �
0
w
Q� � N W O d H
W Q O O u� �
� � O V � ��+
Q 7- '� � Di . �
F' � o
V Q� � a s
� O
� � �
v
d
I Q
. ... ._ _.. .._....._.
y1�,...
� ..
�o
a�
�$
d
o�
�o.�
��
c
� � N
W
a.`� �
o Q
q�V
ap,g u
Nmw
u Q
�^
� � �
� �w
CHECK L1ST OF MEDICAL STANDARDS
GENERAL APPSARANGE:
� T6e applicauc mas[ be frm from any macked deformity, &om
all parasi[it or sYstemic ski� diseases, and fcom evidence of
intemperance in the use of stimulaau or drugs. The body
must be well proporrioued and of good muuulac deve(ap-
ment it must show tareful attenuon to perwaal deanlinas..
Obesity, musculaz wcalcness, or pooc physique must ceject
Girth of abdomen musc not measure more than t6e chest at
IesG
NOSE, MOUTH, AND T'EETH:
Ob.ttruction to ftee breathin8, chronic catajzh, or very offen-
� sive brea[h must reject. The mouth must be &ee. hom deform•
itia or rnndirions [hat incerfere wich diiiina speech or thsc
pred'upose to disease of the ear, nosq or throac There shall
be no disease or hypertcophy of tonsil or d�yroid enlargement.
Teeth must be deao, well cared for, and free from multiple
cavitiat There muu be ac least two molar teec6 to eac6 jaw
on each ride and t6esc tee[h in Sood aPPOSition for proper
masticatiou. The jawe mast be fm from bad(y bxoken ot
decayed teeth thac caano[ be filled or uowned. Missiag ceecL
may be supplied by crowo or bridge work; where site of
teeth mekes tLis impossible, tubber dentures wilt be etcepted.
At leasc tweaty aatural teeth must bc present Pyocrhea will
rejett Bad teech ro be teplaced by deatutes before appoint-
OIeOt W tltpPl[IDC�G
EARS:
Normal hearing wic6 each ear i+ required. Whispuing ��oice,
]0 feer, low voice, 20 feey and loud roice, 80 fee�.
GEIVITALS:
Mwc be free from deformitia and from mazked varic«elq
hydrocele, enlazgemeot of the taude, scricnue, or urinary
iacontinenm Retained testicle or aerophy ieject. Any acure
and all vmereal divases of chese organs must reject.
RECT'CJM AND ANUS:
Fissure; f'utulas, and extzrnel ot interual piles mus[ reject.
VARICOSE VEINS:
A matked tendency [o their fotma[ion musc reject.
ARMS AND LEGS, HANDS ANLI PEET:
Must be free from a&eccions of the joinu, stiHnea, or oc6ec
cnndicious, such as ingsouing naiir, ox hommn4on� w1uc6
woald prevenc the proper and eary performsnce of dnty. Such
, mnditiofls masc be conected befo:e appointment to ihe dr
partment First (index), xcond (middle), and tlurd (rivg)
fingers and tb�mb must be p:esent in their entirety. Great [oe
must be present in iu ent'uety.
�1'E'S:
T6e epplican[ must be free from color blindnqs and ablc
to read with each eye, separately, s�andacd test typn at a
discance of twrnty fee[. Loss of either eye, chronic in8amma-
� cion of the lids, or permaamt abnormalitia of eicher eye
must teject. 20�20 or 20�30 ia oue eye, wit6 biaocular vision
� of 20 f20, as correctable with glasses � .
HER1tRA:
Ac[ual or pocential. hernia ia any fotm mmt reject.
RESPIRATION:
Must be full, easy, and tegular; the respirarory murmur mu�t
be tlear and distinct over both fung; and no disease of c6e
respiracory organs may be present. X•ray of chest !or pouible
tuberculosis involvemenr, to be taken a[ time of eumination.
Posicive 5ndings would rejecc
CIRCULATION:
1'he actioa of the heart must be uniform, free, end steady�
iu thythm regulac, and the 6eatt free fram ocgaaic thsages.
.� Blood ptessure: rynotic maximum 135; dias�oliq 9Q pulse
gcessuce, 15 co 50. .
NERVOUS SYSTEM;
Srain and aervous rystem must be Free from defecb. Epilepsy
� rejects. �
HID�IEYS:
Muit be hea(thy and tbe u:ine normal.
WASSERMAN T'EST:
Will be made before permanm[ appoincmeut
Corrected deficiencies ntust be psove� to fhe Board prior to appoint�nent so the deparlment.
N
ri
�
v.
„d
.Y �
a.,
�
�•J
�
�
�
�
�
F�
M
�
N
i.
ro •
� a�
!-� v
N Q
O f�.�
N «-i
� �
O Fy
•ri O
J> 4y
�
� �
O N
N ��
N [d
� �
.�-.
�
�
�
N
�
d
N •
O �
Q Si
�
H U
C
0
+�
J->
O
�
3
� n
� ��
r-I -J
� �
N �
� �� Fy
� �� N
r-f
� � U
N y�
u �,
N .,-�
q U